Swelling at the back of heel

Pain at the back of the heel, especially when running uphill

Pain while standing on tiptoes

Diagnosis and Investigations

1. History and symptoms: The diagnostic process begins with gathering information about the patient’s medical history and the specific symptoms they are experiencing.

2. Physical examination: A thorough physical evaluation is performed to assess the affected area, checking for tenderness, swelling, range of motion, and any signs of inflammation.

3. Lab tests: Generally, routine blood tests are not helpful in diagnosing typical bursitis. However, in cases of suspected septic bursitis, laboratory markers such as the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and white blood cell count may be elevated, indicating infection.

4. X-ray: While X-rays can’t directly show bursitis, they can be used to rule out other conditions. X-rays of the affected joint are typically ordered when there’s a history of significant injury. A plain X-ray can help identify fractures or dislocations that might be contributing to the pain.

5. CT Scan: Computed tomography (CT) scans are usually reserved for patients whose bursitis doesn’t improve with initial treatment. On a CT scan, superficial bursitis may appear as a fluid-filled area within the tissues just under the skin. Importantly, CT scans can also help detect the presence of any foreign objects within the bursa.

6. Ultrasound Scan: Ultrasound is a valuable tool for confirming a diagnosis of bursitis. On an ultrasound image, bursitis can be characterized by the bursa appearing distended (swollen) with fluid inside (which may appear as a darker or less dense area – hypoechoic or anechoic). The ultrasound can also reveal thickening of the bursal wall (synovial proliferation), calcium deposits, and, in some cases, rheumatoid nodules.

Management and Treatment of Bursitis

Aims

• To reduce the inflammation and pain.

• To identify and treat the cause of the bursitis.

• To prevent complications from developing.

Nursing Management

1. For most bursitis cases, the initial approach focuses on conservative methods to decrease inflammation and pain.

2. Conservative treatment strategies aim to manage pain and inflammation. A helpful mnemonic for remembering these strategies is PRICEMM:

   • Protect: Shield the affected area using padding, braces, or by modifying activities.

   • Rest: Avoid activities that make the pain worse.

   • Ice: Applying cold therapy can help reduce pain and swelling.

   • Compression: Using elastic bandages can provide support and reduce pain, particularly useful for olecranon bursitis (elbow bursitis).

   • Elevation: Raising the injured limb above heart level can help minimize swelling.

   • Modalities: Techniques like electrical stimulation, ultrasound therapy, or phonophoresis (using ultrasound to deliver medication) may be used.

   • Medications: This includes prescribing nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen for pain relief, or administering corticosteroid injections directly into the bursa. Bursal aspiration (draining fluid from the bursa) and injecting corticosteroids (with or without a local anesthetic) may also be performed.

3. Patients whose bursitis is linked to overuse should receive education on the importance of taking regular breaks and exploring alternative activities to prevent the bursitis from returning.

4. Applying cold packs for about 20 minutes at a time, several times a day, may be beneficial during the initial 24 to 48 hours. After this period, heat treatments might be more suitable.

5. Elevation is particularly helpful for bursitis in the legs or feet. Consider specific therapies for different locations (e.g., using cushions for ischial bursitis – affecting the buttocks – or wearing well-fitting, cushioned shoes for calcaneal bursitis – affecting the heel).

6. If septic bursitis is suspected, antibiotics should be started while waiting for the results of lab tests (cultures) to identify the specific bacteria. Superficial septic bursitis can often be treated with antibiotics taken by mouth on an outpatient basis.

7. Patients showing signs of systemic illness (like fever) or those with weakened immune systems might need to be hospitalized to receive antibiotics directly into their veins (intravenous or IV therapy).

8. Surgical removal of the bursa (bursectomy) might be considered for cases of chronic or frequently recurring bursitis. However, surgery is generally a last resort when conservative treatments haven’t been successful.

Medical Management

The medical treatment approach for bursitis varies depending on which bursa is affected and whether an infection is present.

Septic Bursitis

• Systemic antibiotics: Antibiotics that travel throughout the body are the primary treatment for septic bursitis.

  • For bursitis caused by Staphylococcus aureus, antibiotics alone can often resolve the infection.

  • Sporothrix schenckii bursitis, a fungal infection, often requires surgical removal of the bursa (bursectomy) in addition to antifungal medication.

  • Most patients respond well to oral antibiotics, but some may need intravenous therapy.

• Antimicrobial Regimens: Standard antibiotic choices for septic bursitis include:

  • For Staphylococcus aureus, methicillin-susceptible (MSSA):

    • Oxacillin 2 grams intravenously every 6 hours (q.i.d).

    • Dicloxacillin 500 milligrams by mouth every 6 hours (q.i.d).

  • For Staphylococcus aureus, methicillin-resistant (MRSA):

    • Vancomycin 1 gram intravenously every 12 hours (b.d).

Aseptic Bursitis

• Aseptic bursitis is typically managed with the PRICEMM regimen.

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to reduce pain and inflammation.

• Local corticosteroid injections may be considered for patients who don’t improve with initial treatments.

Subacromial Bursitis

• Conservative treatments recommended for nearly all patients with subacromial bursitis include:

  • Physical therapy (PT): Exercises to improve shoulder strength and movement.

  • Scapular strengthening and postural reeducation: Exercises to improve the stability and position of the shoulder blade.

  • Shoulder exercises: Specific movements to restore range of motion and strength.

  • Nonsteroidal anti-inflammatory medications (NSAIDs).

Prepatellar Bursitis

• Conservative treatments recommended for nearly all patients with prepatellar bursitis (bursitis in front of the kneecap) include:

  • Nonsteroidal anti-inflammatory medications (NSAIDs) are often the first-line treatment.

  • Reduce physical activity: Avoiding activities that aggravate the knee.

  • PRICEMM regimen during the first 72 hours after the injury.

  • Physical therapy.

  • Local corticosteroid injections may be used for patients who don’t respond to initial therapy.

Olecranon Bursitis

• Conservative treatments recommended for nearly all patients with olecranon bursitis (elbow bursitis) include:

  • PRICEMM regimen during the first 72 hours after the injury.

  • Avoidance of aggravating physical activity.

  • Most patients get better with these measures, so physical and occupational therapy are usually not needed.

  • Early aspiration (with or without injecting corticosteroids) may help if there’s a significant fluid buildup that’s bothersome.

  • Diagnostic aspiration should be done if the bursitis doesn’t improve with treatment, to check for a possible infection.

Trochanteric Bursitis

• Conservative treatments recommended for nearly all patients with trochanteric bursitis (hip bursitis) include:

  • Modification of physical activity.

  • Weight loss, if applicable.

  • Physical therapy.

  • Nonsteroidal anti-inflammatory medications (NSAIDs).

  • Local glucocorticoid injections are considered for patients whose symptoms don’t improve with other treatments.

  • Physical therapy and NSAIDs are generally the most effective treatments for trochanteric bursitis. Surgery is rarely needed.

Retrocalcaneal Bursitis

• Conservative treatments recommended for nearly all patients with retrocalcaneal bursitis (heel bursitis) include:

  • PRICEMM regimen during the first 72 hours after the injury.

  • Exercises that stretch the Achilles tendon may be beneficial.

  • Limitation of activity and changing footwear to avoid irritation of the back of the heel.

  • Nonsteroidal anti-inflammatory medications (NSAIDs).

  • Physical therapy.

  • Corticosteroid injections are generally not recommended due to the risk of adverse effects on the Achilles tendon.

Surgical Management

Bursectomy

Surgery is typically not the first line of treatment for bursitis. Bursectomy (surgical removal of the bursa) is usually reserved for patients with bursitis that is chronic, keeps coming back, or is infected.

Indications for surgical intervention (either through an open incision or an endoscopic approach) in patients with bursitis include:

• When needle aspiration is not effective in draining an infected bursa.

• The presence of a foreign object within a bursa close to the skin’s surface.

• A nearby skin or soft tissue infection that requires surgical cleaning (debridement).

• Critically ill or immunocompromised patients.

• A chronically infected and thickened bursa.

• Severe bursitis that doesn’t respond to other treatments and keeps recurring.

Prevention of Bursitis

• Engaging in regular exercise.

• Always warming up or doing stretches before physical activity.

• Maintaining a healthy weight.

• Strengthening the muscles around the joints.

• Taking breaks from repetitive tasks.

• Using knee pads when kneeling or elbow pads.

• Avoiding sitting still for long periods.

• Practicing good posture and positioning the body correctly during daily activities.

Complications of Bursitis

• Chronic pain: If bursitis is left untreated, the bursa can become permanently thickened or enlarged, leading to ongoing inflammation and pain.

• Muscle atrophy: Long-term reduced use of the affected joint can result in decreased physical activity and a loss of muscle mass around the joint.